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The Fragile Feet: A Ballerina Story (Part I)

Dr. Pedenof ONS and Greenwich Hospital is an orthopedic surgeon specializing in foot and ankle surgery and treatments for adult foot conditions as well as youth sports injuries in field athletes, gymnasts and ballet dancers. He shares a two-part blog about conditions to be aware of for ballet dancers and gymnasts.

Ballet dancers feet are much like a musician’s hands – they earn a living with them. In addition to putting an amazing amount of stress on their feet, they also are often well below an ideal body weight – either because of the stress of an enormous amount of training or because of unrealistic expectations placed on them by the ballet community. This leads to several different and often unique foot and ankle conditions.

One fairly unique foot and ankle condition in ballet is caused by the en pointe position. In this position an enormous amount of strain is put on the dancer’s great toe, as it is essentially holding up the entire body weight through a small joint. The main flexor tendon of the toe, called the flexor hallicus longus – normally quite small, takes over the job of the largest tendon in the body, the Achilles. The flexor hallicus longus hypertrophies well in compensation for its new job, but unfortunately this tendon is forced through a tight tunnel in the back of the ankle. When it gets too large it will get pinched in the posterior ankle joint. Patients develop painful irritation of the bones and soft tissues in the posterior ankle. An extra bone in the posterior ankle called the os trigonum, which present in about 10% of all people, can be become very painful and irritated in many ballerinas. This constellation of problems is called posterior impingement of the ankle, and it is noticed by the patient as a vague deep pain in the posterior part of the ankle, in front of the Achilles, that is felt with plantarflexion, the position of pointing the foot and toes downward.

Ballet dancers suffer from numerous other problems of the foot & ankle, many of which are not unique. One of the less glamorous problems they deal with are corns, calluses, and blisters. These are necessary adaptations to allow a high level dancer to compete.

Similar to posterior impingement, which arises from dancers spending an inordinate amount of time and stress in an extreme position at the ankle, ballet dancers will develop anterior impingement at the ankle. This comes from repetitive forceful dorsiflexion – pulling the foot and toes upward, toward the shin. Landing from jumps and deep knee bends exacerbate this problem. Pain is felt in the anterior ankle.

Treatment for the above condition is customized to the patient. Often a minor activity modification, or period of rest, can dramatically improve the symptoms. Unfortunately, rest is not easy to come by in the competitive living of a gymnast. Many dancers will treat the symptoms with a combination of anti-inflammatory medications and occasional steroid injections in the region of maximal tenderness. Surgery is a last resort option for any ballerina – when symptoms persist for many months and are limiting, despite all other efforts. Surgery is typically very successful in these patients and can be done with arthroscopic or minimally invasive techniques.

The most common orthopaedic injury of all is also very common amongst ballet dancers: the lateral (traditional) ankle sprain. The mainstay of treatment for ankle sprains is rest, ice, compression, and elevation – mnemonic RICE. A short period of rest and immobilization (1-2 weeks) is followed by aggressive physical therapy, with strengthening of the muscles that stabilize the ankle. Recent research has pointed to improved short and long-term outcomes when early motion and weight bearing is initiated. There is promising early research on the role of stem cell injections – harvested from the patient’s own blood or bone marrow – in the setting of an acute ankle sprain. This is a technique we will offer for the highest level athletes and dancers in certain situations, understanding that the research data on this intervention is still in development.

… to be continued in the next segment, The Fragile Feet: A Gymnast Story (Part II)